Reproductive Health: India Towards 2030

By: Dr Biswanath Ghosh Dastidar

Reproductive Autonomy and Freedom

India recently achieved replacement level fertility with a Total Fertility Rate (TFR) of 2. While this represents a major milestone towards population stabilisation, the unmet need for family planning still stands at 9.4 as per data from the National Family Health Survey 5, which was completed in 2021. When it comes to the use of contraceptives, it still remains low amongst women from ST (48 per cent), OBC (54 per cent) and SC (55 per cent) groups, leading to unintended pregnancies and transmission of sexually transmitted diseases (STDs) including HIV-AIDS. Data from the State of World Population report 2022 indicates that around half of all pregnancies in India are unintended of which over 60 per cent end in abortion. It is also estimated that nearly 45 per cent of all such abortions are unsafe, representing the third leading cause of India’s high maternal mortality ratio (MMR).

As India prepares to meet the G20 in Bali this week, it must prioritise the development of innovative strategies to bridge healthcare gaps in general and address unmet reproductive healthcare needs in particular, if it is to emerge as a global leader at the beginning of an impending new geopolitical era.

It is estimated that around 2.4 million women wanting to avoid pregnancy, currently have an unmet need for modern contraception in India. Women within marginalized socio-economic groups such as ethnic minorities, daily wage workers, sex workers, tribals, dalits and people with disabilities fare relatively worse. Unintended pregnancies which make it to the third trimester and eventual delivery are at greater risk of sub-optimal antenatal care and poor obstetric outcomes further increasing maternal and neonatal deaths, especially in states such as Rajasthan, UP, MP, Chhattisgarh, Bihar, Odisha and Assam. It is also well documented that good maternal health engenders optimal child health and overall better family health outcomes.

The economic costs of ignoring the above are significant. Yet, studies have indicated that every additional Rs 100 spent on contraceptive services would save Rs 252 in the cost of maternal, newborn and abortion-related care that would otherwise be incurred. These are important numbers, especially in the context of a low national expenditure on healthcare, which is around 2 per cent of GDP whilst attempting to lift 134 million citizens from under the poverty line.

However, the unmet need for contraception stems as much from lack of autonomy of choice on the part of the woman, as it does from the lack of access. In our experience of serving night shifts in government hospital labor wards,  it is common to face a situation where a woman hesitates to opt for the insertion of a simple, reversible and safe post-partum intra-uterine contraceptive device (PPIUCD) following a vaginal delivery or cesarean section, rather tremulously referring the decision to her husband or family waiting outside.

Restoring the right to choose essential and appropriate reproductive care to the woman is easier said than done and must begin with firmly acknowledging reproduction itself as a function of bodily choice, freeing it from the status of an indispensable metric of personal accomplishment and family responsibility that it presently enjoys.

Societal taboo towards contraception cannot be altered or even challenged until the agency for self-determination is returned to the woman -- the freedom to conceive a healthy child when desiring conception as well as the freedom to not conceive when not desiring a baby.

This is where infertility must become a part of the greater conversation addressing a couple’s right to fertility management and treatment, particularly in light of recently declining fertility levels in parts of Asia and elsewhere. This would mark a paradigm shift in the national thinking surrounding fertility by addressing conception, infertility and contraception as distinct yet congruent faces of the same prism; demystifying these conditions by discussing them in scientific terms; exploring the equal male and female contribution to these phenomena; and devising strategies to offer access to care across the board.

As India celebrates 75 years of freedom, it is incumbent upon her leaders to offer recourse to freedom to its women -- freedom for self-determination, freedom from infertility, freedom to choose contraception and other reproductive healthcare -- to welcome them into the celebratory fold of Azadi ka Amrit Mahotsav. The introduction of two new contraceptive methods to the national basket at the National Family Planning Summit held by the MoHFW in partnership with the UNFPA makes us optimistic. The recent launch of state-wide, government-funded fertility treatment proposed by the Bengal government provides a promising starting template for universal coverage of reproductive healthcare whilst attempting to level the playing field for the underprivileged.

(Dr Biswanath Ghosh Dastidar is an obstetrician, gynecologist, endoscopic surgeon and infertility-IVF specialist based in Kolkata, India.)

Disclaimer: Views expressed in this article are personal.